VA Maryland Health Care System

Because women are four times more likely than men to get osteoporosis, it's often considered "a woman's disease," but men can get osteoporosis. Two million American men have osteoporosis with another 12 million at risk. Despite the large numbers of affected men, osteoporosis remains under-diagnosed and under-reported. Known as "the silent disease," osteoporosis is generally painless, but it causes bones to become fragile and more likely to break. "Crush fractures of the vertebrae in the back can lead to chronic pain. If not prevented or treated, osteoporosis generally progresses," says Elizabeth Streeten, MD, director of the Metabolic Bone Clinic at the Veterans Affairs (VA) Maryland Health Care System and associate professor of medicine at the University of Maryland School of Medicine.

When bone density is lower than normal it's considered "low bone mass (osteopenia)," diagnosed by DXA (dual xray absorptiometry), a painless 15-minute test to assess bone strength. Not every person diagnosed with low bone mass (osteopenia) will progress to osteoporosis, but risk factors may increase the development of osteoporosis. "Fractures are a major concern for older adults with low bone mass," said Streeten. "For older adults who test with low bone mass (osteopenia), who have not had a fracture, providers  use an online resource called Fracture Risk Assessment Tool (or FRAX) to help decide who needs a prescription medication to help prevent fractures."

What can you do on your own to prevent osteoporosis and fracture?

• Keep body weight in the normal range (low body weight and obesity both increase the risk of fracture).
• Avoid smoking and drinking too much alcohol (more than two drinks per day).
• Do regular weight bearing exercises.
• Add calcium (by taking in dairy products or taking a supplement) and take a vitamin D supplement (1,000 units daily is enough for most adults).
• Avoid falls by removing loose carpets in your home and practicing good safety protocols.
• Speak with a health care provider about osteoporosis. This is important, particularly if taking medicines or managing a chronic disease such as celiac disease, which increases the risk for developing osteoporosis.
• Ask your provider if you need a Bone Mineral Density Test (DXA), the most effective way to diagnose osteoporosis in people who have not had a fracture.  This is a simple 15-minute painless test that calculates the strength of the spine and hip (or forearm if the spine or hip cannot be imaged).

Risk Factors

• Research indicates that genes (family history) are an important risk factor for osteoporosis.
• Other risk factors for osteoporosis and fracture include advanced age, low body weight, low testosterone in men and menopause in women, vitamin D deficiency, smoking, three or more servings of alcohol per day, some medications such as Prednisone and some medical problems. 
• Aging is the most important risk factor for osteoporosis because we all lose bone strength with age.

How is DXA interpreted?

• Bone Mineral Density Test results are reported as a "T score" (in men over 50 and postmenopausal women), which compares bone density to that of healthy young adults. The World Health Organization has defined T-scores as this:Normal bone density: -1.0 to zero and any positive number
• Low bone density or osteopenia: between -1.0 and -2.5
• Osteoporosis: -2.5 or higher negative number
  When DXA is repeated, it is best to use the same testing machine at the same facility. This increases the accuracy of the comparison between the two tests.

What is the FRAX tool?

Developed by the World Health Organization, the Fracture Risk Assessment Tool (or FRAX) calculates the risk of fracture in the next 10 years by including most known risk factors for fracture, in addition to the bone density of the hip (femoral neck) from DXA. Using the FRAX tool helps providers to identify those who have a T-score in the low bone mass range but are at high risk for fracture and need treatment, and to avoid treating those who are at low risk of fracture.

Who should have a DXA?

• All women over 65 and men over 70. Also, any adult with:
• A fracture resulting from a mild fall (eg. from standing height)
• Chronic treatment with prednisone
• Men with low testosterone
• Women being treated for breast cancer with medication to lower estrogen level
• Men with prostate cancer being treated with medication to lower testosterone levels
• Spine fracture or thin bones noticed on X-ray

How is osteoporosis treated?

In addition to calcium, vitamin D and exercise, many medications available now are effective in treating osteoporosis, which reduce the risk of fracture by 50 percent. Your health care provider will determine whether you need medication and if so, which medication is best for you.

Importance of Vitamin D:

• Vitamin D decreases bone loss and lowers the risk of fracture, especially in older men and women. It may also decrease the risk of other chronic illnesses such as diabetes.
• Vitamin D is made in the skin after exposure to sunlight, but most people do not make enough vitamin D to meet their needs and should take a supplement.
• Although there is some controversy about how much vitamin D is ideal, most adults need 1,000 units of vitamin D daily to maintain a normal vitamin D blood level.

How long is osteoporosis treated with medication?

Treatment duration needs to be individualized. For some patients who are at moderate risk for fracture and have responded well to treatment, treatment can be stopped after 5 years. For patients who remain at high risk for fracture after 5 years of treatment, treatment should be continued.

If you are a Veteran enrolled in the VA Maryland Health Care System and want to speak to your VA provider about bone health, call the Appointment Call Line at 1-800-463-6295, ext 7333.